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PROGRAMME FOR INDIA
230
drugs " are to be coloured, which ones are dangerous ? Nupercaine and-’ Amethocaine,’ two of the most potent local anaesthetics. we possess, are probably no more dangerous " in clinical use than procaine, if they are administered in the correct dilution and dose, though each of them is many times more poisonous than cocaine weight for weight. A multiplicity of colours would soon defeat its object. Even procaine, usually considered one of the safest local anaesthetics, can be dangerous : on one occasion 1 g. was -injected into the subarachnoid space in mistake for 100 mg., because the shape of the ampoule used for the two weights was identical, and the administrator did not read the label. Nothing can prevent mistakes of this sort except knowledge and "
constant In the
vigilance. operarting-theatre,
as
in the ward,
great reliance
inevitably be -placed on -the skill and vigilance of sifters and their assistants. Errors on their part easily must
lead to tragedies. For years now there have been occasional deaths owing to confusion between ounces and drachms in doses of paraldehyde.10 Many ward and theatre sisters are unaware of the possibility of these
and the other, tragedies mentioned above. Little or is to theatre sisters nothing donè’in some big hospitals keep up to date with’new developments in the drugs and appliances which they handle. How is the theatre sister to know that ainethocaine is many times by weight more poisonous than procaine ? How is she to know that an injection of 2% nupercaine into the urethra may kill, while 2% nupercaine is permissible in limited amounts as a surface - anæsthetic in the pharynx ? It would probably be helpful for her and her senior assistant to attend the same lectures which inform the senior medical student and resident (and, dare we say it, perhaps even the junior specialist) of these and similar facts. PROGRAMME FOR INDIA
report
11 showed that the Bhore Committee’s India was about twice, and general death<-rate in British the infant-mortality rate about four times, that in England and Wales.. One of the main causes of ill health "an ill-balanced and insufficient was undernutrition : diet giving only about 1750 calories per day was typical of the diets consumed by millions in India." A further principal cause was shortage of trained personnel. Whereas the United Kingdom had 1 doctor to 1000 of the population, British India had 1 to 6000 ; and the position with regard to nurses was much worse-1 to 43,000 in India compared with 1 to 300 in the United
THE
Kingdom. These findings
were recalled by Sir Bennett Hance, himself a member of the committee, in the Birdwood lecture given to the- Royal Society of Arts on Jan. 13. The committee’s long-term proposals, he said, called for the division of the Indian subcontinent into a number of population units ; each, containing about 3 million people, was eventually to be self-sufficient,- training its own medical -and ancillary personnel. These main units were to be subdivided into " primary units " with about 20,000 people. The underlying idea was that, except in sparsely populated mountain tracts, no-one should be more than 10 miles from the primary health centre serving the unit. This centre would comprise a 75-bedded hospital with two doctors in charge; in addition there would be four other doctors to undertake preventive work in the villages and homes.: of the people, and 6 public-health nurses. Aggregations of about
such primary centres, covering -roughly 600,000 inhabitants, were to be organised from so-called secondary
thirty
centres.
Here would be coordinated -the work of the with whole-time heads of the different
primary units,
10. Ibid, 1947, i, 336. 11. See Lancet, 1946, i, 385.
medical departments, and a 650-bedded hospital with full provision for the more usual clinical specialties and a laboratory service for the whole area. Here, too, preventive work would be coordinated. At headquarters would be located the main teaching hospital and research organisation, including a medical college with an annual entry of 50 students and a 2500-bedded hospital with full specialist provision. The committee estimated that it would be possible to produce, within forty years, an integrated preventive and curative National Health Service embracing within its scope institutional and domiciliary provision for health protection of a reasonably high order "; and it advocated meanwhile a short-term programme within the framework of the full scheme. The chief obstacles, said Sir Bennett, were cost and shortage of personnel ; and of these the second was the more serious. At present no more than 2200 doctors could be trained each year ; on this basis 55,000 might be trained in 25 years, whereas the number required in that time was at least 185,000-all of- university standard. The recent constitutional changes, he concluded, might seriously dislocate the time-table of the programme, which he hoped nevertheless to see fulfilled by each of the two new Dominions. Unhappily the costs arising from partition and the war in Kashmir, together with the loss of revenue through Prohibition, are likely to curtail additional expenditure on social welfare ; and for some time to come attention will probably be directed mainly to improving existing medical institutions. "
MUCOSAL FRAGMENTS IN GASTRIC JUICE TEN years ago Hawksleynoted that in 10% of 200 patients submitted to aspiration of the resting gastric juice immediately before, and in preparation for, gastroscopy, the samples contained one or more pieces of gastic mucosa, similar to those which Einhorn,2 in 1894, obtained from the products of gastric lavage. Hawksley-like Einhorn-was convinced that the speci-
he obtained were not torn from the stomach wall suction. In the past two years Hawksley and Cooray3 have adapted this observation to diagnosis, and have confirmed, that in about one aspiration in ten, fragments of mucosa are obtained. The fragments range in size from a pin’s head to a centimetre long. On microscopic study, in all except one, in which carcinomatous tissue was present, the changes of gastritis were observed. The changes are of two main types-those of acute and those of chronic gastritis. In the former, the mucosa is hyperæmic and cedematous, with haemorrhages in the subepithelial and interglandular tissue. In the latter, the histological changes vary : a large proportion show intense infiltration of the interglandular tissue with plasma cells and lymphocytes ; others present evidence of degeneration, atrophy, and faulty regeneration of the epitheliumwhile a few show aggregations of lymphocytes, giving rise to the appearance of follicle formation-follicular gastritis. In chronic atrophic gastritis cystic changes are not infrequent, and there is often a patchy replacement of the gastric-type mucosa by a mucous membrane of intestinal type-superficial intestinal heterotopia. The examination of fresh mucosal tags obtained in this way may help to elucidate the problems of gastritis and enable a correlation to be made between symptoms and pathological changes. It will be unfortunate, however, if the desire for specimens of gastric mucosa encourages the inexpert to exert extra suction on his Ryle’s tube. The junior nurse or student collecting test-meal specimens does not always treat the stomach lining with the respect mens
by
1. Hawksley,
J. C. J. Path. Bact. 1939, 49, 585. Med. Rec. 1894, 45, 780. 2. Einhorn, M. 3. Hawksley, J. C., Cooray, G. H. J. Path. Bact.
1948, 60, 333.
drugs " are to be coloured, which ones are dangerous ? Nupercaine and-’ Amethocaine,’ two of the most potent local anaesthetics. we possess, are probably no more dangerous " in clinical use than procaine, if they are administered in the correct dilution and dose, though each of them is many times more poisonous than cocaine weight for weight. A multiplicity of colours would soon defeat its object. Even procaine, usually considered one of the safest local anaesthetics, can be dangerous : on one occasion 1 g. was -injected into the subarachnoid space in mistake for 100 mg., because the shape of the ampoule used for the two weights was identical, and the administrator did not read the label. Nothing can prevent mistakes of this sort except knowledge and "
constant In the
vigilance. operarting-theatre,
as
in the ward,
great reliance
inevitably be -placed on -the skill and vigilance of sifters and their assistants. Errors on their part easily must
lead to tragedies. For years now there have been occasional deaths owing to confusion between ounces and drachms in doses of paraldehyde.10 Many ward and theatre sisters are unaware of the possibility of these
and the other, tragedies mentioned above. Little or is to theatre sisters nothing donè’in some big hospitals keep up to date with’new developments in the drugs and appliances which they handle. How is the theatre sister to know that ainethocaine is many times by weight more poisonous than procaine ? How is she to know that an injection of 2% nupercaine into the urethra may kill, while 2% nupercaine is permissible in limited amounts as a surface - anæsthetic in the pharynx ? It would probably be helpful for her and her senior assistant to attend the same lectures which inform the senior medical student and resident (and, dare we say it, perhaps even the junior specialist) of these and similar facts. PROGRAMME FOR INDIA
report
11 showed that the Bhore Committee’s India was about twice, and general death<-rate in British the infant-mortality rate about four times, that in England and Wales.. One of the main causes of ill health "an ill-balanced and insufficient was undernutrition : diet giving only about 1750 calories per day was typical of the diets consumed by millions in India." A further principal cause was shortage of trained personnel. Whereas the United Kingdom had 1 doctor to 1000 of the population, British India had 1 to 6000 ; and the position with regard to nurses was much worse-1 to 43,000 in India compared with 1 to 300 in the United
THE
Kingdom. These findings
were recalled by Sir Bennett Hance, himself a member of the committee, in the Birdwood lecture given to the- Royal Society of Arts on Jan. 13. The committee’s long-term proposals, he said, called for the division of the Indian subcontinent into a number of population units ; each, containing about 3 million people, was eventually to be self-sufficient,- training its own medical -and ancillary personnel. These main units were to be subdivided into " primary units " with about 20,000 people. The underlying idea was that, except in sparsely populated mountain tracts, no-one should be more than 10 miles from the primary health centre serving the unit. This centre would comprise a 75-bedded hospital with two doctors in charge; in addition there would be four other doctors to undertake preventive work in the villages and homes.: of the people, and 6 public-health nurses. Aggregations of about
such primary centres, covering -roughly 600,000 inhabitants, were to be organised from so-called secondary
thirty
centres.
Here would be coordinated -the work of the with whole-time heads of the different
primary units,
10. Ibid, 1947, i, 336. 11. See Lancet, 1946, i, 385.
medical departments, and a 650-bedded hospital with full provision for the more usual clinical specialties and a laboratory service for the whole area. Here, too, preventive work would be coordinated. At headquarters would be located the main teaching hospital and research organisation, including a medical college with an annual entry of 50 students and a 2500-bedded hospital with full specialist provision. The committee estimated that it would be possible to produce, within forty years, an integrated preventive and curative National Health Service embracing within its scope institutional and domiciliary provision for health protection of a reasonably high order "; and it advocated meanwhile a short-term programme within the framework of the full scheme. The chief obstacles, said Sir Bennett, were cost and shortage of personnel ; and of these the second was the more serious. At present no more than 2200 doctors could be trained each year ; on this basis 55,000 might be trained in 25 years, whereas the number required in that time was at least 185,000-all of- university standard. The recent constitutional changes, he concluded, might seriously dislocate the time-table of the programme, which he hoped nevertheless to see fulfilled by each of the two new Dominions. Unhappily the costs arising from partition and the war in Kashmir, together with the loss of revenue through Prohibition, are likely to curtail additional expenditure on social welfare ; and for some time to come attention will probably be directed mainly to improving existing medical institutions. "
MUCOSAL FRAGMENTS IN GASTRIC JUICE TEN years ago Hawksleynoted that in 10% of 200 patients submitted to aspiration of the resting gastric juice immediately before, and in preparation for, gastroscopy, the samples contained one or more pieces of gastic mucosa, similar to those which Einhorn,2 in 1894, obtained from the products of gastric lavage. Hawksley-like Einhorn-was convinced that the speci-
he obtained were not torn from the stomach wall suction. In the past two years Hawksley and Cooray3 have adapted this observation to diagnosis, and have confirmed, that in about one aspiration in ten, fragments of mucosa are obtained. The fragments range in size from a pin’s head to a centimetre long. On microscopic study, in all except one, in which carcinomatous tissue was present, the changes of gastritis were observed. The changes are of two main types-those of acute and those of chronic gastritis. In the former, the mucosa is hyperæmic and cedematous, with haemorrhages in the subepithelial and interglandular tissue. In the latter, the histological changes vary : a large proportion show intense infiltration of the interglandular tissue with plasma cells and lymphocytes ; others present evidence of degeneration, atrophy, and faulty regeneration of the epitheliumwhile a few show aggregations of lymphocytes, giving rise to the appearance of follicle formation-follicular gastritis. In chronic atrophic gastritis cystic changes are not infrequent, and there is often a patchy replacement of the gastric-type mucosa by a mucous membrane of intestinal type-superficial intestinal heterotopia. The examination of fresh mucosal tags obtained in this way may help to elucidate the problems of gastritis and enable a correlation to be made between symptoms and pathological changes. It will be unfortunate, however, if the desire for specimens of gastric mucosa encourages the inexpert to exert extra suction on his Ryle’s tube. The junior nurse or student collecting test-meal specimens does not always treat the stomach lining with the respect mens
by
1. Hawksley,
J. C. J. Path. Bact. 1939, 49, 585. Med. Rec. 1894, 45, 780. 2. Einhorn, M. 3. Hawksley, J. C., Cooray, G. H. J. Path. Bact.
1948, 60, 333.